Therapeutic Lifestyle Intervention Research Articles

Cholesterol assimilation by Lactobacillus probiotic bacteria: an in vitro investigation.

Excess cholesterol is associated with cardiovascular diseases (CVD), an important cause of mortality worldwide. Current CVD therapeutic measures, lifestyle and dietary interventions, and pharmaceutical agents for regulating cholesterol levels are inadequate. Probiotic bacteria have demonstrated potential to lower cholesterol levels by different mechanisms, including bile salt hydrolase activity, production of compounds that inhibit enzymes such as 3-hydroxy-3-methylglutaryl coenzyme A, and cholesterol assimilation. This work investigates 11 Lactobacillus strains for cholesterol assimilation. Probiotic strains for investigation were selected from the literature: Lactobacillus reuteri NCIMB 11951, L. reuteri NCIMB 701359, L. reuteri NCIMB 702655, L. reuteri NCIMB 701089, L. reuteri NCIMB 702656, Lactobacillus fermentum NCIMB 5221, L. fermentum NCIMB 8829, L. fermentum NCIMB 2797, Lactobacillus rhamnosus ATCC 53103 GG, Lactobacillus acidophilus ATCC 314, and Lactobacillus plantarum ATCC 14917. Cholesterol assimilation was investigated in culture media and under simulated intestinal conditions. The best cholesterol assimilator was L. plantarum ATCC 14917 (15.18 ± 0.55 mg/1010 cfu) in MRS broth. L. reuteri NCIMB 701089 assimilated over 67% (2254.70 ± 63.33 mg/1010 cfu) of cholesterol, the most of all the strains, under intestinal conditions. This work demonstrates that probiotic bacteria can assimilate cholesterol under intestinal conditions, with L. reuteri NCIMB 701089 showing great potential as a CVD therapeutic.

Review article: management of chronic hepatitis C in patients with contraindications to anti‐viral therapy

There are patients with chronic hepatitis C who are not eligible for the current interferon-based therapies or refuse to be treated due to secondary effects. To provide information on alternative treatments for the management of these patients. A PubMed search was performed to identify relevant literature. Search terms included hepatitis C virus, anti-inflammatory treatment, antioxidant, natural products and alternative treatment, alone or in combination. Additional publications were identified using the references cited by primary and review articles. Several approaches, such as iron depletion (phlebotomy), treatment with ursodeoxycholic acid or glycyrrhizin, have anti-inflammatory and/or anti-fibrotic effects. Life interventions like weight loss, exercise and coffee consumption are associated with a biochemical improvement. Other alternatives (ribavirin monotherapy, amantadine, silibinin, vitamin supplementation, etc.) do not have any beneficial effect or need to be tested in larger clinical studies. There are therapeutic strategies and lifestyle interventions that can be used to improve liver damage in patients with chronic hepatitis C who cannot receive or refuse interferon-based treatments.

Cardiovascular disease risk reduction in rural China: a clustered randomized controlled trial in Zhejiang.

BackgroundCardiovascular disease (CVD) is a major cause of death in China. Despite government efforts, the majority of hypertensive and diabetic patients in China do not receive proper treatment. Reducing CVD events requires long-term care that is proactive, patient-centred, community-based, and sustainable. We have designed a package of interventions for patients at high risk of CVD to be implemented by family doctors based in township hospitals (providers of primary care) in rural Zhejiang, China. This trial aims to determine whether the systematic CVD risk reduction package results in reduced CVD events among patients at risk of CVD compared with usual care, and whether the package is cost-effective and suitable for routine implementation and scale-up.Methods/DesignThis is a prospective, open-label, cluster randomized controlled trial (RCT) with blinded data analysis. The trial will randomize 67 township hospitals with 31,708 participants in three counties in Zhejiang Province. Participants will be identified from existing health records and will comprise adults aged 50 to 74 years, with a calculated 10-year CVD risk of 20% or higher, or diabetes. In the intervention arm, participants will receive a package of interventions including: 1) healthy lifestyle counseling (smoking cessation, and salt, oil, and alcohol reduction); 2) prescription of a combination of drugs (antihypertensives, aspirin, and statin); and 3) adherence support for drug compliance and healthy lifestyle change. In the control arm, participants will receive usual care for hypertension and diabetes management at individual clinicians’ discretion. The primary outcome is the incidence of severe CVD events over 24 months of follow-up. All CVD events will be defined according to the World Health Organization (WHO) monitoring of trends and determinants in cardiovascular disease (MONICA) definitions, diagnosed at the county hospital or higher level, and reported by the Zhejiang surveillance system. Secondary outcomes include: mean systolic and diastolic blood pressure, blood glucose, serum total cholesterol (TC), and adherence to appointments, and drugs and lifestyle changes.DiscussionThis trial focuses on risk reduction of CVD rather than specific diseases. It is not designed to compare therapeutic and healthy lifestyle interventions, but rather their combined effects in primary care settings. Through the trial, we intend to understand the effectiveness of the comprehensive CVD reduction package in routine practice. We also intend to understand the barriers and facilitators to implementing the package, and thus to advise on policy and practice change.Trial registrationCurrent Controlled Trials: ISRCTN58988083

The Counseling Older Adults to Control Hypertension (COACH) trial: Design and methodology of a group-based lifestyle intervention for hypertensive minority older adults

The disproportionately high prevalence of hypertension and its associated mortality and morbidity in minority older adults is a major public health concern in the United States. Despite compelling evidence supporting the beneficial effects of therapeutic lifestyle changes on blood pressure reduction, these approaches remain largely untested among minority elders in community-based settings. The Counseling Older Adults to Control Hypertension trial is a two-arm randomized controlled trial of 250 African-American and Latino seniors, 60years and older with uncontrolled hypertension, who attend senior centers. The goal of the trial is to evaluate the effect of a therapeutic lifestyle intervention delivered via group classes and individual motivational interviewing sessions versus health education, on blood pressure reduction. The primary outcome is change in systolic and diastolic blood pressure from baseline to 12months. The secondary outcomes are blood pressure control at 12months; changes in levels of physical activity; body mass index; and number of daily servings of fruits and vegetables from baseline to 12months. The intervention group will receive 12 weekly group classes followed by individual motivational interviewing sessions. The health education group will receive an individual counseling session on healthy lifestyle changes and standard hypertension education materials. Findings from this study will provide needed information on the effectiveness of lifestyle interventions delivered in senior centers. Such information is crucial in order to develop implementation strategies for translation of evidence-based lifestyle interventions to senior centers, where many minority elders spend their time, making the centers a salient point of dissemination.

THE EFFECT OF THERAPEUTIC LIFESTYLE INTERVENTION ON THE CIRCADIAN RHYTHM OF AMBULATORY BLOOD PRESSURE

ObjectivesTo investigate the effect of therapeutic lifestyle intervention on the restored of circadian rhythm of ambulatory blood pressure.Methods200 hypertensive patients were randomly divided into two groups: therapeutic lifestyle intervention group...

Chylomicronemia Syndrome in Pregnancy: a Case Report of an Acute Necrotizing Pancreatitis.

Introduction: Chylomicronemia syndrome (CS) is a rare disorder characterized by a high level of triglycerides in plasma. We present a case of a pregnant woman with a severe acute pancreatitis (AP) affected by a CS. Case: A 38-year-old gravida 2, para 0 with an uneventful course of pregnancy was referred with an AP at 37 0/7 weeks of gestation. This diagnosis was made from a nearby hospital where the chemical analysis showed elevated pancreatic enzymes with significant hypertriglyceridemia. Because of a pathological fetal heart tracing a caesarean delivery was performed. The APGAR score of the female newborn was 5/8/8 at 1, 5 and 10 minutes, respectively. The pH from the umbilical cord were 7.26 (artery) and 7.59 (vein). Once transferred to our intensive care unit a computer tomography scan confirmed an onset of a necrotizing AP. A conservative treatment was tried without success. For this reason a surgical debridement of the infected and necrosic parts was performed. After a long hospitalisation the patient could be dismissed after 2.5 months in good general condition. Discussion: Lipid profile changes in normal pregnancy are characterized by an elevation of total plasma cholesterol and triglyceride levels. This is normally caused by an increased liver synthesis of triglycerides in response to elevated estrogen levels. When a CS is diagnosed the main goal is to maintain fasting triglyceride levels at less than 500 mg/dL to reduce the risk for AP. Conclusion: Practitioners have an important role in evaluating chylomicronemic patients and implementing therapeutic lifestyle and pharmaceutic interventions aimed to reduce the risk for AP.

Obesity, lifestyle risk-factors, and health service outcomes among healthy middle-aged adults in Canada

BackgroundThe extent to which uncomplicated obesity among an otherwise healthy middle-aged population is associated with higher longitudinal health-care expenditures remains unclear.MethodsTo examine the incremental long-term health service expenditures and outcomes associated with uncomplicated obesity, 9398 participants of the 1994–1996 National Population Health Survey were linked to administrative data and followed longitudinally forward for 11.5 years to track health service utilization costs and death. Patients with pre-existing heart disease, those who were 65 years of age and older, and those with self-reported body mass indexes of <18.5 kg/m2 at inception were excluded. Propensity-matching was used to compare obesity (+/− other baseline risk-factors and lifestyle behaviours) with normal-weight healthy controls. Cost-analyses were conducted from the perspective of Ontario’s publicly-funded health care system.ResultsObesity as an isolated risk-factor was not associated with significantly higher health-care costs as compared with normal weight matched controls (Canadian $8,294.67 vs. Canadian $7,323.59, P = 0.27). However, obesity in combination with other lifestyle factors was associated with significantly higher cumulative expenditures as compared with normal-weight healthy matched controls (CAD$14,186.81 for those with obesity + 3 additional risk-factors vs. CAD$7,029.87 for those with normal BMI and no other risk-factors, P < 0.001). The likelihood that obese individuals developed future diabetes and hypertension also rose markedly when other lifestyle factors, such as smoking, physical inactivity and/or psychosocial distress were present at baseline.ConclusionsThe incremental health-care costs associated with obesity was modest in isolation, but increased significantly when combined with other lifestyle risk-factors. Such findings have relevance to the selection, prioritization, and cost-effective targeting of therapeutic lifestyle interventions.

Abstract 275: Effect of Customized Cardiovascular Education on Patient Beliefs and Behaviors Around Cardiovascular Medications

Objective: The objective of this project was to describe the effect of tailored cardiovascular (CV) patient education on beliefs and knowledge about medication in a nurse managed CV risk reduction clinic. Methods: This prospective project was conducted on patients 18 years of age or older referred to usual care at a risk reduction clinic. The primary analysis was change in scores on the Beliefs about Medications Questionnaire (BMQ) pre and post customized CV education. Education included a background/risk assessment, personalized general information, disease management education, and therapeutic lifestyle intervention. The BMQ evaluates 2 domains: necessity and concerns about medications; and general overuse and harm of medications. Secondary analysis included pre/post scores on a patient knowledge assessment (2 questions: I have received education on the importance of continuing (1) cholesterol medications and (2) antiplatelet medications) and the relationship between specific demographics and BMQ scores pre/post. A power calculation determined 45 patients were needed. Data were analyzed using paired t-tests. Results Forty-five patients were enrolled and 40 completed the project. Average age was 64 years, 55% were male, and average number of medications was 4.5. Results of the BMQ demonstrated significant improvements in response to the following (scale 1 [strongly disagree] - 5 [strongly agree]): “my medications are a mystery to me” (average score pre=2.7 vs. post=2.2, p&lt;0.05) and medications do more harm than good (average score pre = 2.1 vs. post = 2.0; p&lt;0.05). Scores on all other questions were not significantly different pre/post. A higher number of patients responded “yes” that they were instructed on the importance of continuing cholesterol medications and antiplatelet medications pre/post (p&lt;0.05 for both). Age, gender, and education level did not correlate with BMQ scores pre/post. Patients receiving primary prevention therapies showed significant improvements in score in 4 components of the specific necessity and concerns (p&lt;0.05 for all). In 2 areas of general overuse and harm, there were both increases and decreases in scores, respectively (p&lt;0.05 for all). Patients receiving secondary prevention therapies showed significant changes in scores in 12 components. With regard to specific necessity and concern, scores improved in 4 components (p&lt;0.05 for all). A decrease in perception was seen in 1 component (p&lt;0.05). General overuse and harm scores showed improvements in 5 components (p&lt;0.05 for all). A decrease in perception was seen in 2 components (p&lt;0.05 for all). Conclusions: Customized CV education results in improvements in patients’ beliefs and knowledge about medications. These data have provided a basis to further evaluate education methods in this CV practice. Future implications are to investigate changes in BMQ scores with clinical markers such as LDL and blood pressure goal attainment.

RESPONSE TO 190678: TO TREAT OR NOT TO TREAT SHOULD NO LONGER BE THE QUESTION.

In response to our recent study,1 Kwatra et al2 wrote a Letter to the Editor indicating that we missed the opportunity to emphasize the evidence for pharmacotherapy in this population. We were surprised by this comment, because we repeatedly highlighted in our article the need for an effective pharmacological complement to therapeutic lifestyle intervention only for slowing the rapid progression from prehypertension to hypertension. In fact, we stated that the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure recommendation of therapeutic lifestyle change, which includes weight loss, salt restriction, and eating a healthy diet, for example, Dietary Approaches to Stop Hypertension, had limited adoption in the …

A practice-based trial of blood pressure control in African Americans (TLC-Clinic): study protocol for a randomized controlled trial

BackgroundPoorly controlled hypertension (HTN) remains one of the most significant public health problems in the United States, in terms of morbidity, mortality, and economic burden. Despite compelling evidence supporting the beneficial effects of therapeutic lifestyle changes (TLC) for blood pressure (BP) reduction, the effectiveness of these approaches in primary care practices remains untested, especially among African Americans, who share a disproportionately greater burden of HTN-related outcomes.Methods/DesignThis randomized controlled trial tests the effectiveness of a practice-based comprehensive therapeutic lifestyle intervention, delivered through group-based counseling and motivational interviewing (MINT-TLC) versus Usual Care (UC) in 200 low-income, African Americans with uncontrolled hypertension. MINT-TLC is designed to help patients make appropriate lifestyle changes and develop skills to maintain these changes long-term. Patients in the MINT-TLC group attend 10 weekly group classes focused on healthy lifestyle changes (intensive phase); followed by 3 monthly individual motivational interviewing (MINT) sessions (maintenance phase). The intervention is delivered by trained research personnel with appropriate treatment fidelity procedures. Patients in the UC condition receive a single individual counseling session on healthy lifestyle changes and print versions of the intervention materials. The primary outcome is within-patient change in both systolic and diastolic BP from baseline to 6 months. In addition to BP control at 6 months, other secondary outcomes include changes in the following lifestyle behaviors from baseline to 6 months: a) physical activity, b) weight loss, c) number of daily servings of fruits and vegetables and d) 24-hour urinary sodium excretion.DiscussionThis vanguard trial will provide information on how to refine MINT-TLC and integrate it into a standard treatment protocol for hypertensive African Americans as a result of the data obtained; thus maximizing the likelihood of its translation into clinical practice.Trial RegistrationClinicaltrials.gov NCT01070056

Hypertriglyceridaemia in statin‐treated type 2 diabetic patients

AbstractIn this cross‐sectional study, we investigated the prevalence of hypertriglyceridaemia (hyperTG) in 182 statin‐treated type 2 diabetic (T2DM) patients.Predictors of hyperTG (≥2.3mmol/L) were investigated using logistic regression. The prevalence of hyperTG was 20.9%, with lower prevalence in patients with low‐density lipoprotein (LDL)‐cholesterol &lt;2.5mmol/L (13.7%), and LDL‐cholesterol &lt;2.0mmol/L (8.8%). The prevalence of hyperTG plus low high‐density lipoprotein (HDL)‐cholesterol (≤0.9mmol/L) was lower at 6.0%. The independent predictors of hyperTG were waist circumference (odds ratio [OR] 1.033 [95% confidence interval 1.004–1.063], p=0.027) and glucose (OR 1.30 [1.05–1.61], p=0.01), with glucose being the sole predictor in patients with LDL‐cholesterol &lt;2.5mmol/L (OR 1.45 [1.11–1.89], p=0.01) and LDL‐cholesterol &lt;2.0mmol/L (OR 1.59 [1.12–2.26], p=0.01).In this group of statin‐treated T2DM patients, the prevalence of hyperTG was relatively high, but lower in patients with lower LDL‐cholesterol levels. Residual hyperTG in statin‐treated patients could be addressed by therapeutic lifestyle interventions aimed at weight loss and improved glycaemic control and by further lowering of LDL‐cholesterol. Copyright © 2011 John Wiley &amp; Sons.

A Hospital-Based Therapeutic Lifestyle Program for Women With Metabolic Syndrome

The aim of the present study is to evaluate the effect of a hospital-based therapeutic lifestyle program on women with metabolic syndrome (MetS). We conducted a therapeutic lifestyle program for women with MetS. They all received a low calorie, balanced diet and participated in a regular aerobic exercise program for 8 weeks. Anthropometric indices, blood pressure, and biochemical data were collected. A paired t test was used for statistical analysis. A p value of less than 0.05 was considered statistically significant. Forty-four women took part in the program. All the components of MetS had decreased significantly by the end of the program and 25% of women no longer had MetS at the end of the program. The therapeutic lifestyle program with diet control and regular exercise improves most markers of MetS except for levels of high density lipoprotein cholesterol. Therapeutic lifestyle intervention may be the best way of reducing the risk of cardiovascular disease in women with MetS.

Influence of Vascular Oxidative Stress and Inflammation on the Development and Progression of Atherosclerosis

Cardiovascular disease (CVD) risk factors such as hypertension, diabetes, dyslipidemia, smoking, physical inactivity, and obesity increase production of vascular reactive oxygen species (ROS), which results in a reduction of bioavailable nitric oxide and ultimately endothelial dysfunction and endothelial cell activation. ROS appears to mediate the inflammatory pathways that participate in the development and progression of atherosclerosis. There are numerous markers of oxidative stress and inflammation available for assessing the therapeutic response to interventions, but few are currently recommended for clinical use. Exercise training improves endothelial function via several mechanisms, including increased endothelial nitric oxide synthase—nitric oxide (eNOS-NO)— mediated production, increased activity and amount of antioxidants, attenuated ROS production, and an apparent reduction in systemic inflammation, possibly related to an increase in myokines resulting from skeletal muscle activation. Dietary antioxidant supplementation may improve endothelial function, oxidative stress, and inflammation, but much controversy exists regarding the use of antioxidant supplementation in primary and secondary CVD prevention. The purpose of this article is to review the contribution of vascular oxidative stress and activation of the inflammatory pathways in the pathogenesis of CVD and to review common methods used in clinical research to assess vascular oxidative stress and inflammation in response to therapeutic lifestyle interventions.

Physical Activity and Medications: Important Considerations for Fitness and Exercise Professionals

The development of chronic disease conditions (CDCs) is linked to poor lifestyle choices and, consequently, the management of disease is shifting toward therapeutic lifestyle intervention concurrent to drug therapy. Fitness professionals are now commonly working with clients who have various chronic diseases and who may be managing both their disease and associated co-morbidities with pharmacotherapy. Common medications such as non-steroid anti-inflammatory drugs, HMG-CoA reductase inhibitors/statins, ACE inhibitors, calcium channel blockers, ?-blockers, and oral hypoglycaemic agents

Strategies for Implementing and Sustaining Therapeutic Lifestyle Changes as Part of Hypertension Management in African Americans

African Americans with high blood pressure (BP) can benefit greatly from therapeutic lifestyle changes (TLC) such as diet modification, physical activity, and weight management. However, they and their health care providers face many barriers in modifying health behaviors. A multidisciplinary panel synthesized the scientific data on TLC in African Americans for efficacy in improving BP control, barriers to behavioral change, and strategies to overcome those barriers. Therapeutic lifestyle change interventions should emphasize patient self-management, supported by providers, family, and the community. Interventions should be tailored to an individual's cultural heritage, beliefs, and behavioral norms. Simultaneously targeting multiple factors that impede BP control will maximize the likelihood of success. The panel cited limited progress with integrating the Dietary Approaches to Stop Hypertension (DASH) eating plan into the African American diet as an example of the need for more strategically developed interventions. Culturally sensitive instruments to assess impact will help guide improved provision of TLC in special populations. The challenge of improving BP control in African Americans and delivery of hypertension care requires changes at the health system and public policy levels. At the patient level, culturally sensitive interventions that apply the strategies described and optimize community involvement will advance TLC in African Americans with high BP.

The evolving role of medical therapy for chronic stable angina

The management of chronic stable angina has undergone considerable evolution over the past two decades. This article highlights the need for a comprehensive approach to management that includes carefully identifying cardiac risk factors, using therapeutic lifestyle interventions, aggressive, multifaceted medical therapy, and judiciously using myocardial revascularization. For patients whose ischemia cannot be optimally controlled with traditional anti-ischemic agents, a novel antianginal and anti-ischemic agent (ie, ranolazine) has promise in reducing refractory ischemia as add-on therapy. This article discusses the role of coronary artery bypass graft surgery and percutaneous coronary intervention (PCI) in managing chronic stable angina patients and the clinical implications of the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive drug Evaluation) trial. The combined use of a "focal" approach (PCI to treat the culprit stenosis) and a "systemic" approach (lifestyle intervention and aggressive pharmacotherapy) may afford the best event-free survival and clinical outcomes in patients with stable angina.

Insulin Resistance and Parental Obesity as Predictors to Response to Therapeutic Life Style Change in Obese Children and Adolescents 10–18 Years Old

Objective To study insulin resistance and parental obesity as predictors of improvement in weight status in obese children and adolescents undergoing therapeutic life change intervention (TLC). Design A retrospective chart review. Subjects One hundred thirty-four adolescents 10 to 18 years old above the 95th percentile for body mass index (BMI), referred to the Center for Atherosclerosis Prevention from January through December 2003. Measurements BMI, fasting insulin, homeostasis model assessment insulin resistance (HOMA-IR ). Weight management success was defined as BMI Z-score at final exam minus BMI Z-score at initial exam ≤0. Ninety-nine were successful (group S) (reduced or maintained BMI Z-score) and 35 were not successful (NotS) (increased BMI Z-score). Results At baseline there were no differences between the groups in mean age, Tanner stage, gender, severity of obesity, lipid, and blood pressure levels. Insulin resistance was significantly higher in the NotS group compared to the S group as reflected by higher basal fasting insulin levels (21.8 ± 12.3 vs. 15.8 ± 9.0, p = .02), higher HOMA-IR (4.5 ± 2.6 vs. 3.3 ± 2.0, p = .02). After adjustment for age, gender, elevated blood pressure, abnormal lipid profile, baseline BMI Z-score, length of follow-up, and parental morbidity, an increase of 10 units of insulin resulted in a 3.13-fold (95% confidence interval [CI] 1.79–6.01) increased odds of failure. An increase in 1 unit of HOMA-IR resulted in 1.64-fold odds (95% CI 1.27–2.21) of failure. In the same multivariate logistic regression model the existence of obesity-associated morbidity in both parents was associated with 12.6-fold (95% CI 1.93–82.6) increased odds of failure. Conclusions Failing to respond to standard therapeutic lifestyle change intervention was dependent on baseline insulin resistance, and parental obesity-related comorbidity.

The Role of the Diabetes Educator

Therapeutic lifestyle intervention, with a focus on weight loss, is the cornerstone of cardiometabolic risk factor reduction, but many patients find it difficult to make the changes that are needed to achieve meaningful improvements in risk markers. There are a variety of pharmacologic options for the management of individual risk factors, such as hypertension, dyslipidemia, and insulin resistance. However, agents that are currently available to assist patients in their weight loss efforts are limited by their potential for adverse effects. The American Association of Diabetes Educators (AADE) has identified 7 behavioral targets of self-management, the AADE7™ Self-Care Behaviors, which include healthy eating, being active, monitoring, taking medications, problem solving, healthy coping, and reducing risk factors. The case scenarios in the article illustrate some of the challenges clinicians face in managing cardiometabolic risk factor reduction in the context of these recommended behaviors. A common theme among these cases is the importance of assessing patients' understanding, beliefs, and readiness to change their behaviors.

Office Care of Patients After Myocardial Infarction

Declining death rates from heart disease since the 1950s have been largely attributed to secondary prevention. Unfortunately, studies demonstrate remarkable underutilization of secondary prevention plans by health care providers. Health care providers should develop secondary prevention plans for patients who have sustained a myocardial infarction or an acute coronary syndrome. The secondary prevention plan should include four core components: initial patient risk assessment, pharmacologic therapy, therapeutic lifestyle changes and intervention, and psychosocial evaluation.

Therapeutic lifestyle and disease-management interventions: pushing the scientific envelope

Therapeutic lifestyle and disease-management interventions are complex in design, composition and application. Many are multidisciplinary, comprising several individual components[1][1] ([Table 1][2]). An intervention's specific recommendations should be supported by evidence-based practice